Page 1 of 80
“HESI BSN 246 HESI HEALTH ASSESSMENT V1
EXAM PREP ”LATEST EXAM SOLVED
QUESTIONS & ANSWERS VERIFIED 100%
GRADED A+ (LATEST VERSION) WELL REVISED
100% GUARANTEE PASS
HESI Med Surg EXAM COMPLETE QUESTIONS AND ANSWERS | ALREADY PASSED |
2026 LATEST!!, HESI BSN 246 Part II, BSN 246 HESI Health Assessment V1
NEWEST COMPLETE VERSION QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) | ALREADY GRADED A+.
1 The nurse assesses a patient with shortness of breath for evidence of long-
standing hypoxemia by inspecting:
A. Chest excursion
B. Spinal curvatures
C. The respiratory pattern
D. The fingernail and its base
D. The fingernail and its base Clubbing, a sign of long-standing hypoxemia, is
evidenced by an increase in the angle between the base of the nail and the fingernail
to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and
sponginess of the end of the finger.
2. The nurse is caring for a patient with COPD and pneumonia who has an
order for arterial blood gases to be drawn. Which of the following is the
minimum length of time the nurse should plan to hold pressure on the
puncture site?
A. 2 minutes
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B. 5 minutes
C. 10 minutes
D. 15 minutes
B. 5 minutes Following obtaining an arterial blood gas, the nurse should hold
pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has
stopped. An artery is an elastic vessel under higher pressure than veins, and
significant blood loss or hematoma formation could occur if the time is insufficient.
3. The nurse notices clear nasal drainage in a patient newly admitted with
facial trauma, including a nasal fracture. The nurse should:
A. test the drainage for the presence of glucose.
B. suction the nose to maintain airway clearance.
C. document the findings and continue monitoring.
D. apply a drip pad and reassure the patient this is normal.
A. test the drainage for the presence of glucose. Clear nasal drainage suggests
leakage of cerebrospinal fluid (CSF). The drainage should be tested for the presence
of glucose, which would indicate the presence of CSF.
4. When caring for a patient who is 3 hours postoperative laryngectomy, the
nurse's highest priority assessment would be:
A. Airway patency
B. Patient comfort
C. Incisional drainage
D. Blood pressure and heart rate
A. Airway patency Remember ABCs with prioritization. Airway patency is always the
highest priority and is essential for a patient undergoing surgery surrounding the
upper respiratory system.
5. When initially teaching a patient the supraglottic swallow following a radical
neck dissection, with which of the following foods should the nurse begin?
A. Cola
B. Applesauce
C. French fries
D. White grape juice
A. ColaWhen learning the supraglottic swallow, it may be helpful to start with
carbonated beverages because the effervescence provides clues about the liquid's
position. Thin, watery fluids should be avoided because they are difficult to swallow
, Page 3 of 80
and increase the risk of aspiration. Nonpourable pureed foods, such as applesauce,
would decrease the risk of aspiration, but carbonated beverages are the better
choice to start with.
6. The nurse is caring for a patient admitted to the hospital with pneumonia.
Upon assessment, the nurse notes a temperature of 101.4° F, a productive
cough with yellow sputum and a respiratory rate of 20. Which of the following
nursing diagnosis is most appropriate based upon this assessment? A.
Hyperthermia related to infectious illness
B. Ineffective thermoregulation related to chilling
C. Ineffective breathing pattern related to pneumonia
D. Ineffective airway clearance related to thick secretions
A. Hyperthermia related to infectious illness Because the patient has spiked a
temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is
hyperthermia related to infectious illness. There is no evidence of a chill, and her
breathing pattern is within normal limits at 20 breaths per minute. There is no
evidence of ineffective airway clearance from the information given because the
patient is expectorating sputum.
7. Which of the following physical assessment findings in a patient with
pneumonia best supports the nursing diagnosis of ineffective airway
clearance? A. Oxygen saturation of 85%
B. Respiratory rate of 28
C. Presence of greenish sputum
D. Basilar crackles
D. Basilar crackles The presence of adventitious breath sounds indicates that there
is accumulation of secretions in the lower airways. This would be consistent with a
nursing diagnosis of ineffective airway clearance because the patient is retaining
secretions.
8. Which of the following clinical manifestations would the nurse expect to find
during assessment of a patient admitted with pneumococcal pneumonia? A.
Hyperresonance on percussion
B. Fine crackles in all lobes on auscultation
C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all
lobes
, Page 4 of 80
C. Increased vocal fremitus on palpation. A typical physical examination finding for a
patient with pneumonia is increased vocal fremitus on palpation. Other signs of
pulmonary consolidation include dullness to percussion, bronchial breath sounds,
and crackles in the affected area.
9. Which of the following nursing interventions is of the highest priority in
helping a patient expectorate thick secretions related to pneumonia?
A. Humidify the oxygen as able
B. Increase fluid intake to 3L/day if tolerated.
C. Administer cough suppressant q4hr.
D. Teach patient to splint the affected area.
B. Increase fluid intake to 3L/day if tolerated. Although several interventions may
help the patient expectorate mucus, the highest priority should be on increasing fluid
intake, which will liquefy the secretions so that the patient can expectorate them
more easily. Humidifying the oxygen is also helpful, but is not the primary
intervention. Teaching the patient to splint the affected area may also be helpful, but
does not liquefy the secretions so that they can be removed.
10. During discharge teaching for a 65-year-old patient with emphysema and
pneumonia, which of the following vaccines should the nurse recommend the
patient receive?
A. S. aureus
B. H. influenzae
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG)
C. Pneumococcal The pneumococcal vaccine is important for patients with a history
of heart or lung disease, recovering from a severe illness, age 65 or over, or living in
a long-term care facility.
11. The nurse evaluates that discharge teaching for a patient hospitalized with
pneumonia has been most effective when the patient states which of the
following measures to prevent a relapse?
A. "I will increase my food intake to 2400 calories a day to keep my immune
system well."
B. "I must use home oxygen therapy for 3 months and then will have a chest x-
ray to reevaluate."
C. "I will seek immediate medical treatment for any upper respiratory
“HESI BSN 246 HESI HEALTH ASSESSMENT V1
EXAM PREP ”LATEST EXAM SOLVED
QUESTIONS & ANSWERS VERIFIED 100%
GRADED A+ (LATEST VERSION) WELL REVISED
100% GUARANTEE PASS
HESI Med Surg EXAM COMPLETE QUESTIONS AND ANSWERS | ALREADY PASSED |
2026 LATEST!!, HESI BSN 246 Part II, BSN 246 HESI Health Assessment V1
NEWEST COMPLETE VERSION QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) | ALREADY GRADED A+.
1 The nurse assesses a patient with shortness of breath for evidence of long-
standing hypoxemia by inspecting:
A. Chest excursion
B. Spinal curvatures
C. The respiratory pattern
D. The fingernail and its base
D. The fingernail and its base Clubbing, a sign of long-standing hypoxemia, is
evidenced by an increase in the angle between the base of the nail and the fingernail
to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and
sponginess of the end of the finger.
2. The nurse is caring for a patient with COPD and pneumonia who has an
order for arterial blood gases to be drawn. Which of the following is the
minimum length of time the nurse should plan to hold pressure on the
puncture site?
A. 2 minutes
, Page 2 of 80
B. 5 minutes
C. 10 minutes
D. 15 minutes
B. 5 minutes Following obtaining an arterial blood gas, the nurse should hold
pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has
stopped. An artery is an elastic vessel under higher pressure than veins, and
significant blood loss or hematoma formation could occur if the time is insufficient.
3. The nurse notices clear nasal drainage in a patient newly admitted with
facial trauma, including a nasal fracture. The nurse should:
A. test the drainage for the presence of glucose.
B. suction the nose to maintain airway clearance.
C. document the findings and continue monitoring.
D. apply a drip pad and reassure the patient this is normal.
A. test the drainage for the presence of glucose. Clear nasal drainage suggests
leakage of cerebrospinal fluid (CSF). The drainage should be tested for the presence
of glucose, which would indicate the presence of CSF.
4. When caring for a patient who is 3 hours postoperative laryngectomy, the
nurse's highest priority assessment would be:
A. Airway patency
B. Patient comfort
C. Incisional drainage
D. Blood pressure and heart rate
A. Airway patency Remember ABCs with prioritization. Airway patency is always the
highest priority and is essential for a patient undergoing surgery surrounding the
upper respiratory system.
5. When initially teaching a patient the supraglottic swallow following a radical
neck dissection, with which of the following foods should the nurse begin?
A. Cola
B. Applesauce
C. French fries
D. White grape juice
A. ColaWhen learning the supraglottic swallow, it may be helpful to start with
carbonated beverages because the effervescence provides clues about the liquid's
position. Thin, watery fluids should be avoided because they are difficult to swallow
, Page 3 of 80
and increase the risk of aspiration. Nonpourable pureed foods, such as applesauce,
would decrease the risk of aspiration, but carbonated beverages are the better
choice to start with.
6. The nurse is caring for a patient admitted to the hospital with pneumonia.
Upon assessment, the nurse notes a temperature of 101.4° F, a productive
cough with yellow sputum and a respiratory rate of 20. Which of the following
nursing diagnosis is most appropriate based upon this assessment? A.
Hyperthermia related to infectious illness
B. Ineffective thermoregulation related to chilling
C. Ineffective breathing pattern related to pneumonia
D. Ineffective airway clearance related to thick secretions
A. Hyperthermia related to infectious illness Because the patient has spiked a
temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is
hyperthermia related to infectious illness. There is no evidence of a chill, and her
breathing pattern is within normal limits at 20 breaths per minute. There is no
evidence of ineffective airway clearance from the information given because the
patient is expectorating sputum.
7. Which of the following physical assessment findings in a patient with
pneumonia best supports the nursing diagnosis of ineffective airway
clearance? A. Oxygen saturation of 85%
B. Respiratory rate of 28
C. Presence of greenish sputum
D. Basilar crackles
D. Basilar crackles The presence of adventitious breath sounds indicates that there
is accumulation of secretions in the lower airways. This would be consistent with a
nursing diagnosis of ineffective airway clearance because the patient is retaining
secretions.
8. Which of the following clinical manifestations would the nurse expect to find
during assessment of a patient admitted with pneumococcal pneumonia? A.
Hyperresonance on percussion
B. Fine crackles in all lobes on auscultation
C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all
lobes
, Page 4 of 80
C. Increased vocal fremitus on palpation. A typical physical examination finding for a
patient with pneumonia is increased vocal fremitus on palpation. Other signs of
pulmonary consolidation include dullness to percussion, bronchial breath sounds,
and crackles in the affected area.
9. Which of the following nursing interventions is of the highest priority in
helping a patient expectorate thick secretions related to pneumonia?
A. Humidify the oxygen as able
B. Increase fluid intake to 3L/day if tolerated.
C. Administer cough suppressant q4hr.
D. Teach patient to splint the affected area.
B. Increase fluid intake to 3L/day if tolerated. Although several interventions may
help the patient expectorate mucus, the highest priority should be on increasing fluid
intake, which will liquefy the secretions so that the patient can expectorate them
more easily. Humidifying the oxygen is also helpful, but is not the primary
intervention. Teaching the patient to splint the affected area may also be helpful, but
does not liquefy the secretions so that they can be removed.
10. During discharge teaching for a 65-year-old patient with emphysema and
pneumonia, which of the following vaccines should the nurse recommend the
patient receive?
A. S. aureus
B. H. influenzae
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG)
C. Pneumococcal The pneumococcal vaccine is important for patients with a history
of heart or lung disease, recovering from a severe illness, age 65 or over, or living in
a long-term care facility.
11. The nurse evaluates that discharge teaching for a patient hospitalized with
pneumonia has been most effective when the patient states which of the
following measures to prevent a relapse?
A. "I will increase my food intake to 2400 calories a day to keep my immune
system well."
B. "I must use home oxygen therapy for 3 months and then will have a chest x-
ray to reevaluate."
C. "I will seek immediate medical treatment for any upper respiratory
